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Alcohol and Hangovers - Being a Responsible Hedonist.

November 22nd, 2019

Will Jin MD

Resident, Department of Radiation Oncology, University of Miami

Disclosure: Opinions reflect neither employer nor affiliated institutions, soley those of the author.

In the past few decades, there’s been a paradigm shift in the practice of healthcare. The physician of the past was a stern, paternalistic figure who “knew what was best for you”. He dictated medical recommendations to the uninformed patient. In our current age of ubiquitous digital information, patients are supposed to be autonomous decision-makers, who empower themselves, become well-informed, and work with the physician to arrive at a joint medical decision. But commandeering the foreign land of medicine and healthcare still requires a trusting and knowledgeable guide, a role the physician is set to play for the forseeable future.

It’s estimated that 1/3 of U.S. citizens consume alcohol, costing the American workforce $148 billion a year from extra sick days and poor work performance [1]. Alcohol is the most commonly consumed drug in the world yet there isn’t much medical consensus on what to do about hangovers. The scientific term for a hangover is a veisalgia. The term veisalgia, itself, comes from a combination of the Norwegian term kveis for “uneasiness following debauchery” and the Greek root algia for “pain”. But what exactly is a hangover? It’s a rather nebulous term that could describe a constellation of symptoms experienced after consuming alcohol, including but not limited to confusion, headache, shakiness, nausea, vomiting, diarrhea, abdominal pain and fatigue. Why are there so many folk remedies to treat what seems to be as common a problem as diabetes? Why isn’t there a discreet medical recommendation on the treatment of hangovers? Here, I discuss how hangovers produce the symptoms you feel, what the best evidence from the scientific literature says you can do to prevent or treat them, and why there isn’t a “cure” yet. One reason for the lack of evidence-based research on hangovers is the subjective nature of the experience; one person could have absolutely no symptoms save for a slightly parched throat, whereas someone else could have bloodshot eyes, collapsing fatigue, projectile vomiting, or skull-splitting headaches [2-4]. We also know that age plays a role into the extent a person experiences a hangover, suggesting age-dependent metabolism as a major factor [5]. The large variation in symptoms that people experience make it difficult to assess who can actually be helped. An objective definition of a hangover used in the scientific literature include presence of at least two symptoms (headache, poor sense of overall well-being, diarrhea, decreased hunger, shakiness, fatigue, or nausea) occurring after drinking with evidence of full metabolization of alcohol that also causes functional disruption of daily activities [6].

So what exactly is a hangover? There are many validated research papers describing various mechanisms in the laboratory setting, but very few are actually performed in vivo, or in humans. Unfortunately, this leads to numerous deductive theories as to how alcohol eventually produces a hangover, but nothing definitive.

1. When you drink alcohol, or ethanol, it gets converted into a toxic metabolic called acetaldehyde by a liver enzyme called alcohol dehydrogenase [7, 8]. This then receives further metabolic conversion into relatively harmless acetic acid, or vinegar, by acetaldehyde dehydrogenase. It’s theorized that acetaldehyde is partly responsible for some of the ill-feeling effects of alcohol intoxication and hangovers. This molecule causes systemic inflammation and specifically dilates blood vessels near your skin, producing the characteristic “Asian Glow” found in a majority of Asians. Asians are at a higher risk of developing “Asian Glow” and throat cancer because they have a variation of the enzyme acetaldehyde dehydrogenase that functions slower than the wild type, or normal variation [9-11]. The most common effects we see are stomach irritation, nausea center imbalances, and blood vessel dilation, leading to stomach aches, burning sensation in the chest, nausea, vomiting, and flushing.

2. In the brain, ethanol functions like an inhibitory neurotransmitter by mimicking the GABA neurotransmitter [12-14]. GABA receptors are found everywhere in the brain and this means that ethanol inhibits a large portion of brain activity, especially in the centers responsible for balance, decision making, and memory. We see this clinically as a manifestation of gait-ataxia and executive disinhibition, or the characteristic drunk staggering and poor decision-making a drunk person exhibits. Luckily for you, your body is smart. It knows that you can’t function like this for long periods of time. As an adaptive mechanism, your body changes its threshold for inhibition in anticipation of more alcohol-induced GABA activation. But it’s not that smart. It doesn’t know that this is a temporary thing (hopefully). The result is that as soon as you stop drinking alcohol, you lose the inhibitory effect and have an overwhelming surge of brain activation. That’s why alcoholics who go through withdrawals have seizures as their entire brain is suddenly activated and unleashed. (As an aside, I also want to dispel the myth that we only use 10% of our brain at any given time and there’s ways of using 100% of it effectively. If you use 100% of your brain at the same time, that’s called a generalized seizure. You don’t want that.) While this long-term alcoholic withdrawal syndrome is very well described in the medical literature, the short-term version of it is not. One theory describes a hangover as merely a short-term version of an alcohol withdrawal. Once you lose that inhibitory effect of alcohol in the short term, you have a sudden increase in activation of your nervous system. This hypothesis continues with explaining that the symptoms of sweating, blurry vision, increased heart rate and breathing rate are merely hyperactive manifestations of your sympathetic nervous system, or fight-or-flight responses. This lends to the notion that eye-openers or Bloody Mary’s help with a rough morning after a binge night. This also explains why it’s so easy to fall asleep after drinking alcohol, but it’s frequently difficult to stay asleep [15-17]. You fall asleep easily due to ethanol’s initial inhibition effects, but as your brain rebounds with activation from metabolizing the alcohol, it’s too stimulated and produces a form of insomnia. The lack of quality REM sleep, itself, can produce all of the symptoms associated with a hangover.

3. Ethanol also affects many of your hormones, but most importantly is ADH, or anti-diuretic hormone [18, 19]. This hormone is responsible for volume and electrolyte regulation through your kidneys and normally prevents you from peeing. Drinking ethanol makes you pee a lot because it inhibits this hormone. However, it’s not just normal pee; in fact, it’s hypoisomotic or more diluted with water than your normal pee [20-23]. This produces obvious symptoms of dehydration, which can lead to headache and fatigue. More insidiously, it also increases the rate you eliminate water-soluble vitamins, like B and C, and minerals [24-28]. If you’re drinking enough alcohol and don’t normally eat enough green leafy vegetables or fruits, you could be vitamin B and C deficient. In addition to vitamin loss, you’re also losing electrolytes, like sodium and potassium, and albumin, a protein necessary for maintaining water balance. Of course, your thirst centers are stimulated and instinctively drink water as a replacement; but this produces a state of high fluid to low electrolyte and albumin ratio which causes a host of problems itself (that I won’t get into save one, but are mainly redundant from the symptoms I’ve already listed). One of the most prominent issues is full body tenderness and swelling (which is also caused by the systemic inflammation) because you lose the water-drawing ability of albumin in your blood. Your body spaces, like skin, end up trying to maintain an adequate water balance by pulling water from your blood into your skin and swelling you up. A variety of new, non-FDA regulated products are already on the market that aim to address each of the mechanisms for treatment of hangovers [29-32]. The problem with producing effective and convincing research on alcohol-induced hangovers is that the state of a hangover is completely temporary. An overwhelming majority of research on alcohol is performed for withdrawal because of its life-threatening implications. Hangovers are rarely life-threatening and for most people, a non-functionally debilitating nuisance. Alcohol is also completely avoidable and would likely remain as the mainstay for medical recommendations at this time. Like tobacco, it is much more effective from a public health perspective to prevent people from using it in the first place rather than treat some of the temporary side effects. Research needs funding, and will focus on the life-threatening or serious debilitating consequences like lung cancer and alcohol withdrawal, not on hangovers and smelly fingers or yellow teeth. To create the highest level of evidence for support of therapies approved by the FDA, clinical trials are necessary. At this point, it will likely remain unethical to purposefully get people drunk to see what works on treating their temporary problems. However, out of all the studies I reviewed, only one found evidence for reducing hangover symptoms [32]. This study looked at using tolfenamic acid, a non-steroidal anti-inflammatory drug (NSAID) with similar mechanisms as Ibuprofen. This double-blind cross-over study administered 200mg of tolfenamic acid to patients prior to drinking and again prior to sleeping. They found that, compared to control groups, hangover symptoms in the morning were significantly reduced in patients receiving tolfenamic acid.

Everything you’ve read up to this point is meant to be informative, and not a surrogate for a true medical recommendation. My hope is that you use this information to better understand the role that physicians are to play in your active healthcare. While there isn’t a medical consensus on how to effectively treat hangover symptoms, it sometimes may be more dangerous for people to think of their own remedies in an attempt to combat serious symptoms. I’ve combined what the evidence-based scientific literature effective treatment could be systematically direct at remedying each of the ethanol-induced physiologic changes based on a single night of drinking (this does not apply to binge-drinking, multiple day binges, alcohol withdrawals).

Before you drink:
a. Take a Pepcid AC 30 minutes prior to drinking: it’ll reduce stomach irritation and inflammation (and if you’re Asian, it’ll reduce skin flushing).
b. Take a 200mg Ibuprofen 30 minutes before: it’ll reduce systemic inflammation.
c. Take a B and C vitamin multi-complex supplement: it’ll reduce the chance of a water-soluble vitamin deficiency.

While you drink:
a. Rehydrate with pedialyte or coconut water at a 1:1 ratio of what you pee: it’ll reduce the chance of producing a hypoosmotic state.
b. Drink clear liquor: these have less contaminants as they require distillation as part of their process and not from sugar fermentation.

After you drink but before you sleep/crash:
a. Take a melatonin: to try and reduce the chance of delayed onset insomnia (falling asleep easily, but waking up in the middle of the night).
b. Take another 200mg ibuprofen.

Morning after you drink:
a. Drink pedialyte or coconut water the rest of the day: see above.
b. Take a nap: lack of sleep can only be replaced by sleep.

As mentioned above, businesses propped up selling IV infusions of normal saline (salt water) with vitamins, glutathione (reducing equivalents for anti-inflammatory reactions), NSAIDs (anti-inflammatories), anti-emetics (prevents nausea) with a nap to accommodate time for a 2-hour infusion. Warning: I need to mention something obvious, but needs to be stated. Regularly drinking and taking any medication without the right indication is dangerous. Overuse of ibuprofen can lead to stomach bleeds. Drinking alcohol, if you’re Asian and get skin flushing, will still very likely increase your chances of developing throat cancer. The Pepcid AC doesn’t prevent the inflammation, it merely masks it. I am strictly not advocating that anyone should do anything I’ve said above; rather, I want to stimulate a better understanding for the short-term effects of alcohol. Regardless, people are going to continue drinking alcohol and if you’re going to be a hedonist, you should at least aim to be a responsible one.


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